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PAD: Pills, stents & bypasses. ���(Pick one and then keep walking)
Dr Mark Wheatcroft Vascular Surgeon
St Michael’s Hospital
Introduction
• PAD: demographics, natural history
• Best medical therapy
• Further investigation
• Intervention - endovascular vs open
• Outcomes / Follow-up
Disclosure
• No conflict of interest
PAD: A definition • What ankle brachial index (ABI) defines
PAD?
a). More than 1.0
b). Less than 1.0
c). Less than 0.9
d). Less than 0.5
Answer
c). ABI < 0.9
The burden of PAD • 27m people in N. America & Europe with PAD
• 4.3% > 40 years
• 14.5% >70 years
• 2 - 3% per annum non-fatal MI
• CVS mortality rates: 1yr 12%
5yr 42%
10yr 65%
Natural history PAD
ABI < 0.9
Asymptomatic
Intermittent Claudication (IC)
Short distance IC
Rest pain
Tissue loss / ulcer / gangrene
Limb loss / death
Primary presentation
Natural history
Intermittent Claudication
50% Stable
25% Improve
25% Deteriorate
1 - 5% Amputation
PAD risk factors
• The BIG FOUR:
SMOKING X 4
DIABETES X 2
HYPERTENSION X < 2
DYSLIPIDEMIA X 2
Best Medical Therapy • Smoking cessation
• Statin therapy (even if lipids normal)
• Glycemic control in DM
• Antihypertensives - ACE-I
• ASA 81mg / clopidogrel 75mg
• Exercise program
Management • All PAD (inc. asymptomatic): BMT + Exercise
• Symptomatic: Refer to vascular surgery
Intermittent claudication - routine
Critical limb ischemia - urgent
“rest pain”, “tissue loss”,
“ulcer”, “gangrene”.
•
• Need for arterial duplex prior to Vasc Surg questionable
Management - Vasc. Clinic
• Full Hx, Exam.
• Blood work (creat, lipids)
• Arterial duplex with resting ABI +/- post exercise ABI
• Assessment of severity, risks, benefits
• Address risk factors
• CTA, MRA, TFA.
Intervention: Medication
• Pentoxifylline - 12% improvement in WD,
not clinically significant
• Cilostazol - approx 25% improvement in WD
NOT available in Canada
• Ramipril - studied for yrs, recent +ve trial
JAMA 2013; 309 (5): 453 - 460
Intervention: ���Revascularisation
• Is patient suitable? - risks vs benefits
• Is pathology suitable? location, severity, plaque morphology, distal run-off, conduit available?
Intermittent claudication
• Life-style limiting symptoms
• No imminent threat to life or limb
• Period of BMT + Exercise
• Intervention must be low risk
• MIMIC trial supports angioplasty for IC
• Improved WD (but not QoL) Eur. J. Vasc. Surg. 2008 Dec; 36(6): 660 - 668
Intermittent Claudication
• Open procedures (more short dist IC):
Common femoral endarterectomy +/- profundaplasty - PTA resistant
• NOT fem-pop / fem-distal bypass
- Only exceptional cases.
- Too risky for IC.
Critical ischaemia • Urgent!
• Angioplasty / stent vs open bypass
• Depends on lesion and patient fitness / prognosis
• BASIL 2: Primary bypass better if life expectancy > 2yrs
J. Vasc. Surg. 2010; 51: 5S - 17S
Endovascular
• Minimally invasive - day case procedure
• Well tolerated
• Good for short lesions
• Subintimal angioplasty and stenting for occlusions
• Excellent results with iliac stents (70 - 80%)
• SFA stents for longer lesions / occlusions (65% 3yr)
• Tibial PTA less successful, but possible
Angioplasty
TASC II Classification of aorto-iliac disease
TASC II Classification of femoro-popliteal disease
Pre Post
Subintimal Angioplasty
• Technique for crossing chronic occlusions
Endovascular
• Often requires multiple procedures
• Close duplex follow up
• High re-intervention rate
• Need anti-platelet and statin life long
Open Surgery • Iliac disease:
Aorto-bi-iliac / femoral* (>80%)
Ilio-femoral*
Fem-fem X over (75%)
Axillo-bifemoral (71%)
Axillo-unifem (51%)
* rare due to stent success
• CFA / PFA disease: Endarterectomy + patch plasty +/- PFA plasty
Refractory to PTA / stent
• Ilio-femoral disease: Hybrid procedure
• Infra-inguinal Bypass (5yr):
Vein Prosthetic
Fem - AK pop >85% 75%
Fem - BK pop 75% 65%
Fem - distal 70% 25%
Patency
Follow-up
• Lifelong BMT + exercise
• Duplex surveillance
• Endovascular reintervention
• Redo bypass
Worthy of a read......
Vascular Surgery at��� St Mikes
• Dr Mark Wheatcroft
• Dr Tony Moloney
• Dr Wayne Tanner
• Dr Mohammed Al Omran (Chief - Sept 2013)
• Fax referrals to: 416 864 6012
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